Promoting Adherence: From Force to Finesse

Avoidable costs of more than $200 billion are incurred each year in the US healthcare system, with non-adherence accounting for the largest share.

The figures vary a little, but the consensus hasn't changed much in the last decade: non-adherence, in the US alone, is at least a $100-billion-a-year problem, with patients getting sicker, showing up in the ER, or getting an operation that might have been avoided if they'd only taken their meds according to doctor's orders. Of all avoidable US healthcare costs, non-adherence is by far the largest, reports IMS Health (see chart).

Depending on therapeutic area, patient characteristics, insurance coverage, and other factors, estimated non-adherence rates among patients range from 25% to 50% in the US, where nearly half of all adults have at least one chronic disease, according to Centers for Disease Control (CDC). An estimated 10% of hospitalizations in older adults may be attributable to skipping doses, or failing to pick up drug refills.

Everyone knows the statistics but the problem remains despite multichannel disease awareness efforts, new mobile apps, digital tools for tracking health behavior and insurance plan or pharmacy incentives. Efforts to make medicine participatory—instead of rigidly paternalistic—haven't had an enormous impact on non-adherence to date. That's because the choice to take a pill or an injection, in the outpatient setting, is an utterly personal decision—it's based on a panoply of variables, from cost of therapy and the potential for side effects (and how they conflict with day-to-day obligations), to physician trust and the level of comprehension related to risks associated with non-adherence.

It also has to do with plain old forgetfulness, inconvenience, and differing individual priorities. For many patients, collaboration in the context of healthcare decision-making sounds like more work and more effort at a time when jobs and family already compete for any spare time left during the day or night. And yet, "most of what determines [health] outcomes happens outside of the doctor's office," said Farzad Mostashari, a visiting fellow at the Brookings Institution and former National Coordinator for Health Information Technology at HHS, during the SAS Health Analytics Executive Conference in North Carolina last month. What is Mostashari's prescription? "Reduce friction and increase services to promote loyalty." If being adherent to a medication becomes easier than not being adherent, the statistics may finally take a turn.

Greasing the wheels

During a roundtable discussion at the mHealth Summit last December, Vera Rulon, director of external medical communications at Pfizer, recalls sitting next to a diabetes patient who said she "didn't want to be bothered" with a medication regimen, to the extent possible. This patient "wanted something that monitors blood sugar, gives you insulin when you need it or at least alerts you when you need to do something, in a seamless and transparent way," says Rulon. Providing a seamless experience means understanding more than just the nature of a given disease, and a drug's product attributes. It also requires an understanding of the patient, and his or her real-world environment.

"For this particular medication, you do need to look at these factors, and this is what may have an impact on a person's response," for example, says Rulon. "Physicians need to be sensitive to a patient's perspective...building a rapport and trust, and sharing in the decision-making process helps get buy-in for patients to do what they need to do to help themselves."

In addition to actual products that make sustained adherence to therapy an easier pill to swallow are programs that make prescription drugs easier to get. Payers are often seen as the primary barrier to quick and convenient drug access, since a growing number of prescriptions are written for expensive specialty products that require prior authorization, step therapy, or higher co-pays or coinsurance to obtain. Patients taking biologics for chronic disease are often forced to play the same pharmacy counter game of phone tag with insurance companies and physicians every few months, to keep the refills coming.

But insurance providers are partnering with pharmacy benefits managers (PBMs) and even health information companies like WebMD to provide a more convenient way for patients to request and fill prescriptions. Insurers like United Health and BlueCross Blue Shield are experimenting with premium discounts in employer health plans for those patients who can document certain healthy activities, including medication adherence. Pharmacies, too, are launching new service offerings to promote better adherence rates and to build loyalty with patients.

Kaiser Permanente's integrated model puts it in a unique position to combine insights across the payer and pharmacy verticals. Terhilda Garrido, VP of health IT transformation and analytics at Kaiser, says patients can digitally access their own personal health records without having to enter any data themselves, and can also request refills, and even ask for mail order and pay with a credit card. Garrido says one of Kaiser's basic models is to "make the right thing easy to do," which in this case means getting prescription refills to patients with minimal effort. Like an http://Amazon.com/ purchase, Kaiser's patients can sign on and click to get a product order—in this case a medication refill—delivered by mail. "I've actually used it myself," says Garrido. "I've studied this stuff, but when you actually use [a refill delivery program], you think, 'Wow, this is pretty great.'"

Since online refill requests for prescription mail order are routed through one of Kaiser's fulfillment houses (which is "much more automated than the local facility at the medical center or clinic"), it's a lower cost-per-script filling rate, says Garrido. "So, we're thrilled about some of the advantages that being on the Internet is giving to our patients."

Kaiser invested $4 million in electronic health record (EHR) technology 10 years ago, a decision that "catalyzed our use of data," says Garrido. Now, the organization leverages its 10 petabytes of EHR data—and its four thousand data analysts—to push risk claims down and close gaps in care, including non-adherence. One program, called the Outpatient Medication Safety Net, uses an "adherence ratio" to predict when a patient will run out of medicine. This information—and whether a script was filled on time—is then passed to the physician through the patient's EHR. "Then the physician can say, 'I notice that you didn't pick up your statin. Let's talk about that, and why it's important and why I prescribed it, and what [barrier] might be getting in the way,'" says Garrido. "We're presenting that information to physicians to enable a conversation that in fact does increase adherence rates."